Sr. Claims Compliance Professional

Humana; Bismarck (ND); À distance; USD 86 000 - 119 000; Plein temps

Résumé du poste

Humana, Inc. is seeking a Senior Compliance Professional to perform oversight audits of claims delegates, ensuring adherence to state and federal regulations and Humana standards. You will develop relationships with internal and external partners and drive corrective actions to maintain audit readiness.

The role emphasizes data analysis, reporting, and collaboration with compliance teams to propel process improvements and regulatory readiness across the organization.

Qualifications

• 2+ years of claims and/or audit experience.
• Knowledge/understanding of claims.
• Demonstrated proficiency in MS Word, Excel and PowerPoint.
• Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards.
• Ability to travel up to 20% to site delegations.

Responsabilités

• Efficiently track, report, and communicate all audit information to delegates and required internal departments.
• Prepare detailed audit reports and present findings to management and relevant stakeholders.
• Review and analyze the delegates’ policies and procedures as well as claims files (medical, mental health and vision) for accuracy, completeness and policy compliance, validating coding, billing and documentation against regulatory requirements.
• Issue corrective action plans as applicable and monitor implementation until resolution.
• Serve as primary contact for assigned claims delegates, ensuring compliance with contractual and regulatory requirements.
• Develop and maintain key relationships with assigned delegates to optimize business results.
• Maintain detailed documentation of oversight activities, audit results and compliance status for reporting.
• Use data analysis tools and audit software to monitor trends and support quality assurance.
• Assist in special projects that promote department efficiency.
• Collaborate with claims processors and compliance teams to resolve issues and improve processes.
• Help develop and update delegated oversight policies, procedures and training materials.
• Support readiness for regulatory audits and accreditation surveys by ensuring delegates meet standards.

Connaissances

Claims knowledge

Audit proficiency

Regulatory understanding

Strong communication

Formation

Bachelor’s degree

Outils

MS Word

Excel

PowerPoint

Description du poste

Become a part of our caring community

Be a part of Compliance – Use your business knowledge to help analyze and develop policies, procedures and programs supporting our compliance initiatives. As a Senior Compliance Professional, you will perform oversight audits of our claims delegates to ensure compliance with current state/federal regulations, as well as Humana standards. You will serve as the primary point of contact for assigned claims’ delegates, auditing medical, mental health and vision claims and driving corrective actions through resolution to help keep Humana and our delegates audit ready.

Humana is seeking a Senior Compliance Professional to develop and maintain key relationships by working with internal and external business partners to evaluate and maintain compliance.

• Efficiently track, report, and communicate all audit information to delegates and required internal departments. Prepare detailed audit reports and present findings to management and relevant stakeholders.
• Review and analyze the delegates’ policies and procedures as well as claims files (medical, mental health and vision) for accuracy, completeness and policy compliance, validating coding, billing practices and documentation, to ensure they are compliant with regulatory and legislative requirements
• Issue corrective action plans as applicable. Work with the assigned delegates until the issue has been resolved. Monitor implementation and follow up to ensure timely resolution and sustained compliance.
• Serve as the primary point of contact for assigned claims delegates, ensuring compliance with contractual, regulatory and Humana requirements.
• Develop and maintain key relationships with the assigned delegates to optimize business results.
• Maintain detailed documentation of oversight activities, audit results and compliance status for internal and external reporting.
• Use data analysis tools and audit software to monitor trends and support quality assurance.
• Assist in special projects that promote department efficiency.
• Collaborate with claims processors and compliance teams to resolve issues and improve processes.
• Help develop and update delegated oversight policies, procedures and training materials.
• Support readiness for regulatory audits and accreditation surveys by ensuring delegates meet all applicable standards.

What makes you successful in this role:

• Being knowledgeable in process improvement
• Strong written and verbal communication skills
• Strong attention to detail
• Being able to manage multiple or competing priorities and meet deadlines
• Performing work assignments without direction and exercising considerable latitude in determining objectives and approaches to assignments
• Excellent communication skills, both oral and written, including the ability to present audit findings and influence delegates to resolve deficiencies
• Ability to effectively represent Humana, with a high level of professionalism, when working with external delegates

Use your skills to make an impact

Required Qualifications

• 2+ years of claims and/or audit experience
• Knowledge/understanding of claims
• Demonstrated proficiency in MS Word, Excel and PowerPoint
• Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards
• Ability to travel up to 20% to site delegations

Preferred skills:

• Bachelor’s degree
• Experience with delegation laws, regulations and accreditation requirements, such as CMS, NCQA and applicable state requirements
• Claims experience
• Auditing experience, including medical, mental health or vision claims
• Working knowledge of coding standards (ICD, CPT and HCPCS) and the ability to validate coding, billing and documentation against regulatory requirements
• Experience with audit methodology, such as sampling, root cause analysis and scorecards or dashboards
• Experience using data analysis or audit tools to monitor trends and support quality assurance
• Project coordination or management experience
• Metrics and report development experience
• Vendor management experience
• Certifications such as CHC, CCEP, CPC, CIA or CFE

Additional Information:

• This role is fully remote within the US. For Applicants located in Louisville, KY/Indiana the workstyle is hybrid based on team rotation from the Waterside Building.
• In this role you will report to a Compliance Lead.
• This role will have travel-based oversight to site delegations.

Work at Home Requirements:

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

$86,300 - $118,700 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 11-17-2026

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.